Provider Demographics
NPI:1164549945
Name:MYERSON, LARRY
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:
Last Name:MYERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 REDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08361-6769
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:39 S BROADWAY
Practice Address - Street 2:
Practice Address - City:PITMAN
Practice Address - State:NJ
Practice Address - Zip Code:08071-1413
Practice Address - Country:US
Practice Address - Phone:856-589-2392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI01311300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist